Traumatized refugees: identifying needs and facing challenges for mental health care

ABSTRACT In the past few years the number of refugees worldwide has increased dramatically. Many of them were traumatized in their homelands due to violent conflict or persecution, as well as during their flight, and are confronted with ongoing stressors in the exile countries. In order to contribute to enhancing the clinical knowledge, this special issue of the European Journal of Psychotraumatology focuses on traumatized refugees. It includes three review articles as well as four original articles on the mental health burden, screening instruments and interventions in different groups of refugees. The articles published in this special issue focus on important aspects of better understanding the needs of traumatized refugees, as well as on identifying and offering appropriate mental health care for this population. Future research recommendations are provided in the hope to contribute to improving mental health care strategies of this still underserved population.

International studies show that refugees suffer from increased rates of short-term and long-term mental health problems: approximately one in three refugees is suffering from PTSD or other trauma-related mental disorder (Bogic, Njoku, & Priebe, 2015;Fazel, Wheeler, & Danesh, 2005;Steel et al., 2009). Despite the urgency to offer treatment, there is limited knowledge about the mental health burden of, and effective interventions for, traumatized refugees (Acarturk et al., 2015;ter Heide, Mooren, & Kleber, 2016). Currently, the best evidence for reducing traumarelated mental health problems in refugees can be found for trauma-focused interventions, such as narrative exposure therapy (Crumlish & O'Rourke, 2010;Nickerson, Bryant, Silove, & Steel, 2011;Nosè et al., 2017). Other forms of psychosocial interventions are not well studied. There is a need to study psychosocial interventions in different refugee populations, focusing on their effectiveness but also on aspects of feasibility and cultural adaptation.
European Journal of Psychotraumatology has a strong tradition focusing on global mental health issues and populations forced to migrate (see special issues Hall & Olff, 2016;Purgato & Olff, 2015;Turner, 2015). To enhance clinical knowledge, this special issue focuses on traumatized refugees. It includes three review articles as well as four original articles on the mental health burden, screening instruments and interventions in different groups of refugees. The first article gives an overview on the mental health status in North Korean refugees in South Korea and focuses on the risk and protective factors in this little studied population (Lee, Park, & Lee, 2017). The first review ever conducted on the mental health of North Korean refugees summarizes the findings of 56 studies, reporting high prevalence rates of symptoms of posttraumatic stress disorder (PTSD), depression and anxiety. Risk and protective factors, pre-and post-settlement factors as well as personal factors associated with mental health are presented. The authors identify several risk factors, such as traumatic exposure in North Korea and during flight, acculturative stress, poor physical health and age. Repatriation and length of stay in a third country seem to be additional risk factors specific for this population; protective factors include higher educational and economic background before flight and social support.
In a systematic review and meta-analysis, an overview of the effectiveness of psychosocial interventions for displaced war-traumatized minors is provided focusing on symptoms of PTSD, depression, anxiety, grief and general distress (Nocon, Eberle-Sejari, Unterhitzensberger, & Rosner, 2017). The authors conclude that Cognitive Behavioural therapy (CBT) and Interpersonal Therapy showed promising results, needing further replication. Few treatment studies were available for the population of children and adolescents, mostly with low methodological quality, and most of the interventions resulted in no significant improvements of mental health problems.
The third review article focuses on the special situation of Syrian refugees, their mental health conditions, and scalable evidence-based interventions. It outlines the newly launched STRENGTHS programme for adapting, scaling up and testing Problem Management interventions (Sijbrandij et al., 2017).
Very little research has been done on the validity of instruments for refugee populations (Wind, van der Aa, de la Rie, & Knipscheer, 2017). The first research article in this special issue describes the evaluation of the Refugee Health Screener 15 (RHS-15), a screening instrument for common mental health problems in refugees, in a sample of 86 refugees residing in Germany (Kaltenbach, Härdtner, Hermenau, Schauer, & Elbert, 2017). The RHS-15, as well as the shorter RHS-13, showed good feasibility, reliability and validity in the self-rating as well as in the interview version.
This issue continues with the cultural adaptation and evaluation of a CBT programme for Farsispeaking refugees, that was conducted with male refugees from Afghanistan and Iran (Kananian, Ayoughi, Farugie, Hinton, & Stangier, 2017). The transdiagnostic intervention conducted in a group setting shows promising results in terms of reducing general psychopathological stress and improving quality of life.
In the third research article, 76 adult patients at a treatment centre for torture victims and traumatized refugees were surveyed in the context of their regular multidisciplinary psychotherapeutic treatment (Stammel et al., 2017). The study shows that symptoms of traumaassociated disorders decline and quality of life improves over the course of treatment. Younger age was associated with greater reductions of somatoform symptoms.
Finally, a group-based multidisciplinary day patient treatment for refugees who experienced multiple traumatic losses was evaluated (de Heus et al., 2017). In this article, data from 14 patients who participated was analysed, supporting the feasibility and potential effectiveness of the programme.
The articles published in this special issue focus on important aspects to better understand the needs of traumatized refugees, as well as on identifying and offering appropriate mental health care for this population. Cultural sensitive psychotraumatology remains a priority (Schnyder et al., 2016) and rigorous treatment research, whether randomized controlled trials or innovative intervention research paradigms, is needed. For future research the need for low-threshold, cost-effective interventions for refugees with mental health problems, such as online-supported interventions or transdiagnostic approaches, should be considered and alternative types of interventionsintegrative and complementary approachesas well as making better use of e-health opportunities deserve further investigation (see call for papers). The European Journal of Psychotraumatology looks forward to receiving more papers focusing on traumatized refugees, to improve the mental health care strategies of this underserved population.

Disclosure statement
No potential conflict of interest was reported by the authors.